Stigma Toward Bariatric Surgery in the Netherlands, France, and the United Kingdom: Protocol for a Cross-cultural Mixed Methods Study

Background Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients’ perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched. Objective This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom. Methods This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels. Results The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients’ perspectives. Qualitative data will provide insights into patients’ experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country. Conclusions The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery. International Registered Report Identifier (IRRID) PRR1-10.2196/36753

Review of Open Round 2019 PhD project "Stigma towards bariatric surgery: Prevalence and impact in the Netherlands, France, and Germany" [FG4] Please, rate each aspect on a four-point scale between outstanding and poor by ticking the appropriate box. Please also explain your evaluation. Thank you very much for you co-operation and please return within two weeks to Wageningen School of Social Sciences: e-mail to: wass@wur.nl

Scientific quality
Comments: I would say that it would be more informative to start with the interviews and then base the questionnaires on the interviews. That way you will have more information and more points of view, which you might miss when starting with questionnaires. The project seems very feasible.

Comments:
The two groups seem to really complement each other in knowledge and I think thereby collaboration will improve different aspect of the project. What I miss here is more explanation of how these group will collaborate, making sure that the central goal will be achieved.

Rebuttal Stigma towards bariatric surgery: Prevalence and impact in the Netherlands, France, and Germany
Dear members of the WASS committee, I would like to thank the reviewer for taking the time to review my proposal and for providing constructive feedback. In regard to the terminology used, I agree that we should use an appropriate term when referring to people living with obesity, and therefore will use the term as suggested whenever possible. Below I address additional points discussed in the review.

Connection between stigmatization and treatment outcomes
The reviewer indicates that the relevance of the proposed research could be further strengthened by incorporating the connection between stigmatization and treatment outcomes in the research. I agree with the reviewer that treatment outcome is a very important aspect of stigmatization, one that requires, and will gain, considerable attention in the proposed research. Below I will outline the current evidence on the (unfavourable) relationship between stigmatization and patient outcome for Bariatric Surgery (BS).
The clinical effectiveness of BS is often measured in terms of achieving significant weight loss and the improvement of obesity-related disease (Hopkins et al., 2015). In order to facilitate weight loss and prevent weight regain it is essential for individuals to adhere to a strict diet and exercise regime post-surgery (one that requires considerable effort). Bariatric patients who experience stigma post-surgery are less likely to adhere to these dietary and exercise guidelines (Raves et al. 2016;Hans et al. 2018).
Currently most studies investigating the impact of stigma on BS (indirect) outcomes are quantitative in nature and those of qualitative nature have mostly taken patients perspective into account. To my knowledge, only one mixed method study exists investigating the impact of stigma on patient outcomes from both the patients and health care professional's perspective (Raves et al. 2016). This study, focusing primarily on dietary adherence, showed that BSpatients and health care professionals think differently about the impact of stigma on treatment outcomes. Patients felt that stigma influenced outcomes and health care professionals thought the reverse relationship to be more accurate (Raves et al. 2016). To fully understand how stigma is constructed and to fully capture the impact of stigma on bariatric surgery treatment outcomes more research is needed, not only from the perceptive of patients but also from the perspective of health care professional. The proposed study will address this research gap.

Qualitative data as input for survey study.
The reviewer suggests that it would be more informative to start the project with participant interviews and based the surveys on these interviews. As a result, this would provide more points of view than when starting off with the questionnaire. I would like to thank the reviewer for this helpful suggestion.
To ensure that the questionnaire fully reflects the perspective of people living with obesity and BS patients I have now decided to indeed first conduct the semi-structured interviews. The results of these interviews (together with the results of a literature review) will be used for questionnaire item generation. This way of developing a questionnaire is, according to experts, the most appropriate way of ensuring content validity, a fundamental element of questionnaire validity (Ricci et al., 2019).

Collaboration between chair groups
The reviewer states that the two groups involved in the project complement each other in knowledge and that collaboration will benefit the project. However, the reviewer expresses that there is limited information on how these two groups will collaborate to ensure the goal of the project is achieved. Below I will try to elaborate on the foreseen collaboration.
Both chair groups will be involved in all phases the research project as both groups have extensive general expertise with research projects of a multi-, inter-, or transdisciplinary nature and with mixed-methods studies. Specific expertise of the chair groups will be used for all research phases (including, research set-up, selecting appropriated comparative design and methods, data analysis, & dissemination). For example, HSO and RSO use different ontological perspectives and theoretical perspectives to analyses social (health) issues. While HSO has extensive knowledge on research focused on understanding and solving society relevant challenges and complex health issues from a social-ecological perspective, RSO has extensive knowledge on and experience with conducting international (geographical) comparative studies within Europe (but also with countries such as Ecuador, India, and Turkey). This knowledge and experience will be used to collect and analyse data from France, Germany and the Netherlands. Throughout the project regular meetings and discussions (approximately once a month) on progress and next steps will take place, this way researcher can share content, perspectives, and insights and learn from each other. Prof. dr. Maria Koelen will be the promotor of the project and Prof. dr.ir Hans Wiskerke the co-promotor. Given that the project involves a set of complex societal questions that cross disciplines (and countries), an integrated research collaboration between both chair groups is essential to achieve the goals of the research project.
I hope that this rebuttal letter addresses the comments by the reviewer sufficiently.